September 09, 2013

The Passion of the Health Care Fixer

The first President to take a shot at fixing health care was a Bull Moose trying to become President one more time. Unfortunately Teddy Roosevelt failed to win those elections and instead of providing “protection of home life against the hazards of sickness, irregular employment and old age through the adoption of a system of social insurance”, America took the low road leading to the Great Depression. Fixing health care was on the minds of all subsequent occupants of the White House, from FDR to Barack Obama, to varying degrees, but as America’s circumstances and character evolved over many decades, so did the understanding of why and how health care should be fixed.

For Franklin D. Roosevelt “[t]he right to adequate medical care and the opportunity to achieve and enjoy good health” were part of a second Bill of Rights to provide security at home for all Americans. It was a lofty attempt to “assure us equality in the pursuit of happiness". FDR failed to implement his progressive fix for health care, and Harry Truman although even more passionate than his predecessor, achieved little in his own health care fixing attempts. It fell to Lyndon B. Johnson, a southern democrat, to create Medicare and Medicaid, taking the first step towards Truman’s vision of a “national system of payment for medical care”. Although much tinkering and heated rhetoric followed, the second step was never taken. Until now.

As our President expanded Medicaid to include a larger fraction of the growing masses of poor people, and created federal subsidies for unofficially poor people to purchase the now mandatory health insurance, an army of experts at everything from Toyota manufacturing systems to silicon chips design are professing their passion for fixing health care. But the passion of today’s health care fixers is different. When Harry Truman spoke of health care, he spoke of those who “suffer needlessly from the lack of proper medical care”. And FDR spoke of the dangers of being content when “some fraction of our people—whether it be one-third or one-fifth or one-tenth- is ill-fed, ill-clothed, ill housed, and insecure”. John F. Kennedy spoke of “working men and women” subjected to the indignity of “being forced to beg for help from public charity once they are old and ill”.

Today, we speak of the imperative to cut health care expenditures and the need to balance budgets and reduce deficits. Our sympathies are with employers who are contributing too much towards workers’ health care, and we argue that freeloaders must be prevented from getting health care at our expense, and that the poor must be diverted from seeking care at expensive medical venues. The passion of contemporary health care fixers is not about human pain and suffering. It’s not about humiliation and social injustice. It’s not about preserving freedom and democracy or pursuing happiness. It’s not about the people at all. It’s about money.

It was a late evening sports injury resulting in a swollen ankle in fifty shades of purple. After nipping the ER idea in the bud, and dutifully waiting until the next morning, I made a same-day appointment with a reputable orthopedic practice and a doctor we never met before. There was no waiting and the sweet and friendly nurse breezed through all the meaningful use nonsense, which was not pertinent to this visit in any way, and then she and her laptop left the room. The doctor walked in thirty seconds later, with no laptop, no chart and nothing else in his hands. Soft spoken and businesslike, he examined the ankle, ordered the obligatory x-rays, walked out and several minutes later walked back in telling us that nothing is broken, but we’ll be getting a boot to help the healing process, and then walked out again. Exactly what I expected from a specialty visit. But then something strange happened. The nurse could not find a proper Ace bandage and while she was fumbling in the hallway, the doctor walked back in, pulled a little package from some drawer, sat down on the low stool and slowly and methodically bandaged the swollen ankle, making small talk about bandages always being the wrong size. So here was this distinguished orthopedic surgeon, specializing in knee and hip replacements, wrapping an elastic bandage around a little girl’s mildly sprained ankle. He was definitely not practicing at the top of his license, and neither was his nurse, and during those 30 seconds of pure waste, the aloof stranger became my daughter’s doctor. She would keep the boot on although it looked yucky, and she would make an effort to put weight on that foot, and she’ll come back in two weeks to see him, and the doc was smiling faintly as he was leaning against the door before we left.

If FDR had his way, fixing health care would extend the best health care in the world to all people “regardless of station, race, or creed”. If we have our way, and we will, this type of health care will cease to exist for most Americans, because there is no ROI for highly trained surgeons to tend to children’s falls and bruises, unless of course the child happens to live in the ruler’s palace, or Bel-Air, or Alpine NJ. Fixing health care today means learning from India or Nepal, or any random third world country mired in corruption or despotism. Fixing health care means spread of innovation where people who can barely afford breakfast dispense medical advice from mobile vans parked on street corners to those who are immobile in many ways, while calculating the exact dollar amounts of savings realized by such bold innovation. And fixing health care means cool technology.

Technology of the type recommended to fix health care is manufactured for pennies a day, by children existing in those countries we are supposed to learn from; children who were not lucky enough to be born in the greatest country in the world. Harnessing the wonders of technology to fix health care means giving all poor people a shiny blue button to click on, so they can see how well the mobile van driver cared for them, and perhaps share the information with the next mobile van that will be tending to their needs. I can’t begin to tell you how distraught my daughter was when realizing, that unlike the 60,000 former soldiers residing on park benches across the country, she had no blue button to click on. There were no open-notes for us to peruse the next day, and neither the doctor nor his team of people searching for Ace bandages, made any attempts at partnering with us, and we were not empowered to choose wisely. Nobody suggested that the follow up visit be with some “other care giver”, or be conducted electronically from the comfort of our home. I guess, my daughter’s orthopedic surgeon is not a passionate health care fixer, so he forgot to flip his clinic.

But more than anything else, today’s highly educated health care fixers are passionate about knowledge, because you cannot cut costs of things you don’t know about. Imagine how much more effective caring for a sprained ankle could be if I only knew exactly what the surgeon got paid for all the knee and hip replacements he performed last year, not to mention the ability to have a list of every prescription he wrote, every test he ordered and every pharmaceutical bagel he ate since the sun began shining. They used to say that knowledge is power, but in our fixed health care, knowledge is also money, and lots of it. As Robert Henley, 1st Earl of Northington and the Lord Chancellor of Great Britain observed in 1762, and as Franklin Delano Roosevelt, the President of the United States of America reiterated in 1945, “[n]ecessitous men are not free men". Since both “necessitous” and “free” are now relative terms, thus open to personal interpretation, perhaps it is unfair to criticize the abundantly necessitous passion of health care fixers yearning to be free. I therefore preemptively apologize.